When President Donald Trump posted a satirical music video on social media in early October depicting his price range director, Russell Vought, because the Grim Reaper lording over Democrats in Congress, public well being employees acknowledged a kernel of reality.
Vought has exerted extraordinary management over authorities spending this yr, usurping congressional selections on how the nation’s cash is used. His push for extra layoffs throughout the federal government shutdown is barely the newest blow, following months of firings, canceled grants, and withheld funds.
By reducing and freezing public well being funds, specifically, the Trump administration has already begun to undercut efforts to offer medical care, outbreak response, housing help, and analysis throughout the U.S., in keeping with well being officers, nonprofit administrators, and federal company staffers interviewed by KFF Well being Information.
Since most federal funds for public well being move to states, Vought is rivaling the Division of Well being and Human Companies secretary, Robert F. Kennedy Jr., in his means to upend government-led efforts to maintain People wholesome. In Texas, Facilities for Illness Management and Prevention funds to stem a measles outbreak weren’t obtainable till after the disaster had subsided and two kids had died. A mission to guard Alabamans from uncooked sewage and hookworm was deserted. Individuals with HIV have needed to delay medical care as clinics reduce hours. Time-dependent surveys on HIV and maternal mortality have been halted. Meals banks have canceled occasions. Tobacco prevention applications lapsed. Initiatives to guard older adults liable to falling have been harried.
It doesn’t matter what price range Congress in the end passes for subsequent yr, the Trump administration might proceed to thwart monetary assist for such applications in methods that can hurt folks’s well being. “The White House has shown that they are willing to unilaterally exert control over funding,” stated Gillian Metzger, a constitutional legislation professor at Columbia College.
“This is a huge deal,” she added, “because the power of the purse is central to Congress’ ability to shape and direct policy.”
Earlier than he was appointed to guide the White Home’s Workplace of Administration and Funds this yr, Vought outlined budgetary methods the manager department might deploy to wrest energy from Congress and federal businesses in Mission 2025, the Heritage Basis’s conservative blueprint.
Vought’s techniques unfolded this yr, typically under the radar. They embody abrupt grant cancellations, extraordinary constraints on how funds may be spent, and extreme layers of evaluate, company officers say, at each step within the grantmaking course of. Getting cash out the door has been additional sophisticated by layoffs which have gutted workplaces overseeing grants on continual illness prevention, HIV, maternal mortality, and extra.
Authorities staff have described these techniques to members of Congress, stated Abigail Tighe, government director of the Nationwide Public Well being Coalition, a bunch that features present and former staffers on the CDC and HHS. “We want Congress to act, because this is preventing states and communities from doing critical public health work to keep our country safe,” she stated. “If they don’t have capacity, we all collectively suffer.”
Democrats on the Home and Senate appropriations committees have pushed for transparency, however the extent to which cash Congress appropriated for public well being in 2024 and 2025 has gone unspent due to the administration’s disruptions is just not but recognized. “This is a sophisticated strategy to cause money to lapse and then say, ‘If they can’t spend it, they don’t need it,’” stated Robert Gordon, a public coverage specialist at Georgetown College and a former assistant finance secretary at HHS.
“No one thought this was possible or legal, but that is what’s happening,” he stated.
Particulars on how the administration has subverted well being spending have obtained little consideration as a result of many adjustments have been made quietly — and individuals who depend on federal funds concern retribution. The Trump administration has defunded and threatened federal workplaces that maintain the federal government accountable and fired whistleblowers. It has abruptly revoked funds for native governments and organizations.
Vought and spokespeople on the White Home and the OMB didn’t reply to queries from KFF Well being Information. Nonetheless, Vought described his intentions in a Sept. 3 speech. He stated that federal businesses and Congress had gained extra energy over spending for the reason that Seventies and that their management grew to become “woke and weaponized” beneath Presidents Barack Obama and Joe Biden.
“Thankfully, President Trump won,” he stated. “And we have now been embarked on deconstructing this administrative state.”
Many Components, Many Malfunctions
Like a automotive, the federal price range course of has many parts that may break down. Via the OMB and its associate, Trump’s Division of Authorities Effectivity, or DOGE, the administration has intervened at varied junctures. “There are so many ways in which money is not operating in the way it is supposed to operate,” stated Bobby Kogan, the senior director of federal price range coverage on the Heart for American Progress, a left-leaning assume tank, and a former OMB adviser.
Usually, Congress passes a price range that appropriates cash for the following fiscal yr to federal businesses. For a lot of public well being applications, starting from housing help to most cancers screening, businesses then submit open calls on-line for states, native governments, and organizations to use for funding. Company consultants choose winners and ship notices of awards — or notices of ongoing funding to teams that beforehand gained multiyear awards.
Subsequent, the OMB, which administers the federal price range, prompts cash for businesses, like a financial institution prompts a bank card, in order that grantees can spend and get reimbursed quickly. Auditors keep watch over spending, however the authorities has up to now restricted interruptions in order that applications run easily.
Early on, the Trump administration canceled billions of {dollars} in awards granted in 2024 and early 2025 for analysis and international well being. In March, it clawed again $11.4 billion in covid-era funds that Congress had earmarked for well being departments that have been utilizing the cash for illness surveillance, vaccinations, and extra.
Though some funds have been restored due to lawsuits, the Supreme Court docket has allowed different cuts by the administration to face whereas the instances transfer by means of the courts.
Past these “shotgun” cancellations, the administration has taken a quieter, “in-the-weeds, slowing, cutting, conditioning” method that’s frozen funds for public well being, stated Matthew Lawrence, a legislation professor specializing in well being coverage at Emory College.
By August, the CDC’s middle for HIV and tuberculosis prevention had doled out $167 million lower than the historic common, in keeping with an evaluation by the Heart on Funds and Coverage Priorities, a assume tank centered on lowering inequality. The CDC’s funding for continual illness prevention lagged by $259 million, the Ryan White HIV/AIDS Program had underspent by $105 million, and funds for psychological well being on the Substance Abuse and Psychological Well being Companies Administration have been greater than $860 million behind what was anticipated.
An unknown quantity of Congress’ 2025 funding for analysis and public well being has but to be awarded and can in all probability lapse this yr, stated Joe Carlile, an creator of the middle’s evaluation and an affiliate OMB director in the course of the Biden administration. The obstructions seem like concentrated in areas the place the White Home proposed reducing the federal price range subsequent yr. “The administration may be executing their 2026 budget request through administrative controls,” Carlile stated.
“This is boring but crazy-high stakes,” he added. “A one-branch veto of spending neuters the power of the purse in the Constitution that Madison said was the fundamental check on the executive branch.”
Incremental Chaos
A key tactic Vought described in Mission 2025 happens when the OMB prompts funds for businesses in installments, referred to as apportionments. Vought wrote that “apportioned funding” might “ensure consistency with the President’s agenda.”
Below Vought, the OMB shrank the scale of apportionments, HHS and CDC staffers stated. It’s unlawful for businesses to let grantees withdraw cash earlier than the full quantity is within the metaphorical financial institution, in order that delayed businesses’ means to greenlight spending.
The OMB and DOGE additionally positioned circumstances on apportionments by means of memos, footnotes, and spoken directives telling businesses to make sure that spending “aligns with Administration priorities,” in accordance to reviews and HHS staff who stated that notices of funding alternatives and awards required extreme layers of sign-off. The CDC and different businesses circulated lists of priorities that replicate White Home stances, together with these concentrating on range, fairness, and inclusion efforts; immigration; and transgender rights. Public well being efforts have been particularly caught up in crimson tape, since many deal with populations bearing an unequal burden of loss of life, illness, and harm.
Teams that depend on federal funds have largely been unaware of the explanations grants have been held up, however they’ve fielded what they seen as unsettling queries. For instance, Kathy Garner, the pinnacle of a Mississippi nonprofit, stated officers requested her to defend the exclusion of males from a program to shelter girls who skilled home violence.
Delays have been made worse by uncertainty. Grantees stated they’ve been unable to succeed in program officers as a result of tens of hundreds of federal employees have been laid off. Company officers stated firings sluggish funding additional.
“Everyone’s inbox is full of letters from grant recipients asking, ‘How do we proceed?’” one high-ranking CDC official advised KFF Well being Information, which granted company officers anonymity due to their fears of retaliation. “We just say, ‘Please wait.’”
Time was essential as a measles outbreak surged in West Texas early this yr. The state requested for federal funding for the response in March, but it surely didn’t arrive till Could, after the outbreak had largely pale in Texas, in keeping with an investigation by KFF Well being Information. Apportionment management was a key motive, CDC staffers stated.
In July, 81 HIV organizations despatched a letter to Kennedy. “With every day of delayed FY2025 funding release, the delivery of essential HIV services is compromised,” stated the letter, which was reviewed by KFF Well being Information. Due to delays and uncertainty, it stated, HIV clinics had laid off case managers and lowered clinician hours, closed websites, and pared down hotlines that sufferers name with pressing questions. The funds arrived a couple of month later, however HIV suppliers stay shaken.
Lauren Richey, medical director at College Medical Heart’s HIV clinic in New Orleans, backed out of hiring a sorely wanted dentist she had recruited. “I was afraid to tell someone to move across the country for a job when I wasn’t sure if or when we’d get the funding for their salary,” she stated. “The wait is now three to four months for dental services, when it was usually a couple of weeks at most.”
Tamachia Davenport, program director on the St. John AIDS outreach ministry in New Orleans, stated that “a lot of us are having to rob Peter to pay Paul.”
When the group didn’t get CDC funds it anticipated this summer season, Davenport needed to resolve between reducing workers or provides. Involved her prime staff would take jobs elsewhere, she stopped shopping for the condoms they distribute all through the town to forestall the unfold of sexually transmitted infections.
Louisiana already has one of many highest charges of HIV, chlamydia, and gonorrhea within the nation. Condoms value far lower than treating these illnesses. For an individual contaminated by HIV at age 35, such prices exceed $326,000.
Teams centered on most cancers, diabetes, and coronary heart illness additionally report lasting repercussions from delays, in addition to ongoing fears that they may occur once more. Louisiana State College’s Wholesome Ageing Analysis Heart canceled a few of its workshops to coach well being employees on caring for folks with dementia. “There may be fewer people who have this very specific expertise next year in Louisiana and Mississippi,” stated Scott Wilks, the director of the middle. “That’s on top of the big shortage we have already.”
Nationwide surveys tallying maternal and toddler mortality froze for about 5 months due to funding delays, inflicting an irrecoverable hole in knowledge that had been collected constantly since 1987, CDC officers say.
“We are seeing the administration get their way with or without an approved budget,” one stated. “It’s such a terrible shame to play with people’s health this way.”
DOGE additionally inserted itself into grant reimbursements this yr, stalling the speedy turnaround that public well being teams usually anticipate to cowl salaries, lease, and different month-to-month prices outlined in budgets which have already been accepted. In what’s now labeled Departmental Effectivity Evaluation, itemized bills should be frequently justified by a number of authorities officers, in keeping with paperwork reviewed by KFF Well being Information.
DOGE posted on its web site expense reviews overlaying a couple of month’s span from April to Could. Almost 230 of the person bills filed to federal businesses throughout that interval are for $1 or much less. Different entries break down month-to-month salaries for particular person staff and petty prices for postage or month-to-month subscriptions.
“Public funds deserve scrutiny, but this is different from audit practices I’ve been a part of,” Carlile stated.
DOGE additionally stalled calls for functions for 2025 funding — and a few calls by no means appeared because the fiscal yr got here to an in depth on Sept. 30. Amongst them are applications for teams that present housing help. Individuals will probably be evicted when these organizations run out of cash left over from 2024, stated Steve Berg, chief coverage officer on the Nationwide Alliance to Finish Homelessness.
Different solicitations got here out months not on time, leaving teams with just a few weeks to place collectively sophisticated functions for multimillion-dollar awards, together with for Alzheimer’s care, habit restoration, senior assist, and continual illness administration.
“They’ve set projects up to fail,” one HHS official stated.
